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Patient Name___ Date of Birth___POLICY Integral Health is dedicated to providing quality health care including health education and preventative care services to all members of the community regardless

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How to fill out sliding scale fee application

01

Obtain a sliding scale fee application form from the organization

02

Fill out personal information such as name, address, contact number

03

Provide details of income and expenses to determine financial eligibility

04

Submit the completed application form along with required supporting documents

Who needs sliding scale fee application?

01

Individuals or families who are looking for financial assistance to pay for services or programs offered by the organization

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What is sliding scale fee application?

Sliding scale fee application is a form used to determine the amount an individual or organization will be required to pay for a service based on their income or financial situation.

Who is required to file sliding scale fee application?

Individuals or organizations who may qualify for reduced fees based on their income or financial situation are required to file a sliding scale fee application.

How to fill out sliding scale fee application?

To fill out a sliding scale fee application, individuals or organizations must provide information about their income, expenses, and financial situation as requested on the form.

What is the purpose of sliding scale fee application?

The purpose of sliding scale fee application is to ensure that individuals or organizations with limited financial resources are able to access services at a reduced cost.

What information must be reported on sliding scale fee application?

Information such as income, expenses, assets, and other financial resources must be reported on a sliding scale fee application.

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